beyondblue guide to the management of depression in primary care A guide for health professionals

www.beyondblue.org.au

1300 22 4636

Contents About this guide

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Appendix 1

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Part 1 | Assessing the problem 2

Assessing the severity of depression

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Part 2 | Making a diagnosis

Appendix 2

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A guide to undertaking a suicide risk assessment

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Appendix 3

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Part 3 | Planning management of depression

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If able to be managed in primary care

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ICD-10 description of mania (manic episode) ICD-10 description of a depressive episode

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Notes

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Resources

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Resources to give to patients Resources for General Practitioners

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Appendix 4

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Symptoms of the melancholic sub-type (ICD-10 somatic syndrome)

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References

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About this guide This guide is in three parts: • Assessing the problem • Making a diagnosis • Planning management and matching evidence-based treatments to the diagnosis. It is designed, in particular, for use by General Practitioners (GPs) and their patients. The word depression can be used to describe a mood (sometimes normal, sometimes signalling a problem) or an illness (or disorder). It is a word that has meaning in common parlance as well as in the clinical setting. Whether we are talking about the common parlance depression, or a severe clinical depression, each may require help, be it from friends, family or professionals.

Murtagh’s safe diagnostic strategy can be useful here – whereby the doctor looks for the common probability diagnosis, as well as considers the less common, but serious, not to be missed diagnoses (Murtagh, 2007). Principal author Professor David Clarke Professor of Psychological Medicine at Monash University, Clinical Director at Southern Health, former Research Advisor at beyondblue, bbDMHP Advisory Committee

General Practitioners often work at the problem level. Disorders are diagnosed when the depression is severe or prolonged, and when there is interference with normal daily functioning. The following taxonomy acknowledges that there is a range of distress for which people come for help. General Practitioners deal with the whole range.

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Part 1 | Assessing the problem This guide is designed to aid General Practitioners in their enquiry with a patient, moving from the commonsense meaning of depression through to a diagnosis of clinical depression – a disorder. Although the distinction between normal sadness and clinical depression is often a hard one to make, perhaps it does not matter all that much. A person in distress who comes for help needs help. The question is selecting the best and most appropriate form of help. Questions to be asked are: 1. Is this person distressed and/or depressed (in the common sense meaning of depressed)? A person may spontaneously admit to being depressed. Alternatively, their depression may be recognised by another person, a friend or a doctor. Common indicators are: • a change from usual mood, behaviour or demeanour • a sullen look, loss of sparkle in the eyes, loss of joy

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2. How severe is this depression? (Should I be concerned?) Severity is determined by: i. presence and severity of symptoms of depression ii. level of impairment of daily functioning iii. degree of hopelessness or suicidal thought. Appendix 1 gives a guide to making a judgment of severity of depression. Much of this is done through the elicitation of symptoms. However, a significant contributor is also the empathic understanding of the level of sadness, hopelessness, shame and giving up – things that are often communicated non-verbally. Enquiry of suicidal thought, and an assessment of risk, needs to be undertaken if: • the depression is severe • there is expressed feelings of helplessness or hopelessness

• apparent loss of interest in things, social withdrawal

• there is a pervasive (not situational) loss of enjoyment (anhedonia).

• crying or unusual moods, including irritability.

Appendix 2 summarises how to assess suicide risk.

3. How long and how much of the time have these symptoms been present? To make a diagnosis of clinical depression symptoms must be: • persistent – for several weeks; at least two but probably more • pervasive – present in all situations e.g. not ‘depressed at home, but happy at work’. 4. What is the context of the depressive symptoms? Ask the patient why they think they might be feeling this way, or “And what else has been going on in your life during this time?”. Note: although the context will guide the treatment to some extent, the absence of an identifiable specific situational context or cause does not mean that help or treatment is not available.

5. Past history and family history • Has there been any prior episode of depression? • Has there been anything like a manic episode in the past? (see Appendix 3 for a description of mania) • Is there a family history of depression, mania or non-specific mental breakdown? 6. Co-morbidity – other accompanying problems Is there a significant other problem complicating the situation that will require attention, such as: • an anxiety problem • an alcohol or drug problem • an active medical condition.

Is there, or has there recently been: i. A bereavement • i.e. the death of someone close. ii. Some other acute event or loss • e.g. diagnosis of a physical illness, loss of job, loss of a relationship, a traumatic event. iii. Chronic stress • e.g. in family, relationship or work. iv. No apparent life event or chronic stress • Could there be a physical cause of the change in mood? e.g. a new medication, menopause or a recent inflammatory illness.

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Part 2 | Making a diagnosis Before planning management or treatment of depression, a multi-level diagnosis needs to be made.

The following table provides a framework for the key elements of this.

Multi-level diagnosis

4

Primary diagnosis

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Severity of depression

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1. Is the primary diagnosis depression and what type of depression is it? The ICD-101 criteria shown in Appendix 3 provide a guide to making a formal diagnosis of depression. However, we also need to consider the full range of depression types. These are illustrated in the tear-out flow chart at the back of this booklet. Consider the probability diagnoses which include stress, grief and hopelessness depression – sometimes called demoralisation – and the not‑to‑be‑missed diagnoses such as melancholic depression and bipolar disorder. The specific characteristics of the melancholic form of depression are listed in Appendix 4. Consider also the possibility of chronic depression. 2. Are there any important secondary (co-morbid) diagnoses? Consider especially: • anxiety

3. Write a formulation – a paragraph answering the question “Why is this person ill in this way at this time?” Note especially: • nature of stressor: why is this a stressor for this person? • personal strengths and vulnerabilities • social networks – supports or vulnerabilities. 4. Quantify severity of depression • Use Appendix 1 as a guide to determine mild, moderate or severe status. • In addition, scales such as the PHQ-9, K10, DASS, SPHERE or Demoralisation Scale can be used to give a score of severity that may be compared with later measurements to monitor progress. 5. Note your assessment of risk • See Appendix 2 for a guide.

• alcohol abuse • personality contribution (dispositionally anxious, angry, obsessional, depressed, low self esteem, labile moods, sensitive to rejection) • active medical condition and/or on medications.

 The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines. Geneva, World Health Organization, 1992.

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Part 3 | Planning management of depression The issue of safety and place of care are important questions: Can this person be managed in primary care or do they require urgent mental health assessment or supervision (i.e. assessment by a mental health crisis team) or referral to a psychiatrist?

• co-morbidity – especially anxiety and alcohol abuse

If able to be managed in primary care

Interventions are generally determined not so much by the diagnosis of depression, but by the elements of the depression most strongly present. In this sense, treatment is symptomatic or problem-based. For instance, see Box 1.

Management will depend on: • severity

• expectation – will this depression resolve naturally, albeit with support and counselling? • patient preferences and availability of treatment options.

• nature of depression (e.g. grief, stress reaction, hopelessness depression, melancholic depression) (see tear-out flow chart) Box 1: Principles of matching presentation with an appropriate therapeutic response If the main issue is…

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The intervention will be…

Grief and loss

➤

Comfort, reassurance, counselling, mobilising support

Realistic assessment of practical problems

➤

Problem solving; and if the problems are insoluble, help with adjustment, re-setting of goals and expectations, strengthening social support and coping

Unrealistic evaluations (cognitive distortions)

➤

Identifying and challenging dysfunctional thinking

Depression does not come in pure form. Often there is an element of grief (something lost that will not be regained), a problem (that requires problem solving), loss of joy (needing pleasant event scheduling) and/or cognitive distortions (requiring identifying and challenging). All patients require behavioural activation to bolster self-efficacy, reduce feelings of helplessness, increase hope and strengthen their active participation in the recovery process.

These help diminish the feelings of anxiety, helplessness and aloneness that are invariably present when people become depressed. Exercise, good sleep and nutrition will increase vigour. At times, doctors will empathically feel the same helplessness and demoralisation felt by the patient. It is important in these circumstances that the doctor is able, after reflection, to step back and see a positive way forward, providing confidence and hope for the situation.

Melancholic depression (sometimes called endogenous depression) does represent a clear sub-type of depression – perhaps representing a biogenic depression, requiring medication. It is especially characterised by pervasive anhedonia (loss of pleasure), consequent loss of reactivity of mood, and physical and mental slowing (psychomotor retardation) (See Appendix 4). Remember also to consider what has helped in the past. Box 2 presents a way of putting all this together and matching treatment to the type of depression/distress. Remember, all patients will benefit from (see tear-out flow chart): • reassurance, information, explanation and problem solving • the common factors in therapeutic counselling (empathic listening and reflecting back) • behavioural activation, mobilisation of social support, sleep hygiene, encouragement of healthy lifestyle behaviours.

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Box 2: Matching depressive syndrome with intervention Depressive syndrome type

Intervention

Grief reaction • Mild-moderate-severe mood disturbance • Understandable as a reaction to the loss

Comfort, listening, reassurance, counselling, mobilising social support, problem solving

Stress (adjustment difficulties) • Mild-moderate distress • Understandable in the context of the stress (either specific events or chronic stress) • Expected to resolve (perhaps with help) when the stressor remits

Counselling, problem solving, watchful waiting. If the depression/distress persists (either beyond the stress or the stress persists): • consider medication – particularly if melancholic symptoms are present • consider cognitive therapy – particularly if cognitive distortions are present.

Hopelessness depression (severe demoralisation) Moderate-severe depression marked by Beck’s ‘cognitive triad’ feelings of: • worthlessness (about the self) • pessimism (about the world) • hopelessness (about the future).

Cognitive therapy is most appropriate. Antidepressant medication could be used either initially, or after cognitive therapy is established if symptoms have not resolved fully.

Melancholic depression Characterised by symptoms of: • anhedonia (loss of joy and pleasure, non-reactive mood) • physical slowing, not eating • cognitive slowing.

Antidepressant medication is indicated. Some form of psychotherapy (cognitive, interpersonal or brief dynamic therapy) is useful once the medication has begun to have an effect.

If anxiety is prominent:

specific treatment for anxiety is required, such as: • cognitive therapy • relaxation and stress reduction • exposure – facing the fears • antidepressants may also help reduce anxiety and the frequency of panic attacks.

Anxiety is characterised by: • anxious and worrying thoughts • physical arousal and difficulty sleeping • avoidance of anxiety-provoking situations.

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Depressive syndrome type

Intervention

If excessive alcohol use is present:

• specific attention to alcohol abuse is required • goals of management depend on level of use: Hazardous drinker ➤ controlled drinking Dependent drinker ➤ abstinence Recalcitrant drinker ➤ harm minimisation • assess motivation for change, reinforce safe drinking behaviour.

(The AUDIT questionnaire may assist evaluating the degree of any alcohol problems)

If active physical disease, injury or illness is present:

• maximise control of the physical disease and associated symptoms • use principles of Chronic Disease Self Management to strengthen the patient’s sense of control over their illness and to reduce helplessness • although there are some drug interactions to consider, in general the same pharmacological, behavioural and psychological treatments are effective for depression in the context of physical illness.

Chronic depression Enduring personality traits and poor quality relationships are often important maintaining factors in depression.

A combination of helps and supports are required to minimise disability and distress, such as: • supportive counselling – regular appointments plus help when necessary • controlling stress, strengthening coping behaviours • maintenance on antidepressant medication.

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Now, on the basis of the clinical assessment from pages 8 and 9 and treatment considerations, write a Mental Health Management Plan. The Mental Health Management Plan What?

When?

By whom?

Further investigation required: • Pathology tests • Mental Health Assessment Need for information

Behavioural advice

Specific counselling or psychotherapy: • Grief counselling • Problem solving • Cognitive • Interpersonal Social supports

Medication

Referral

Clinical review

On the basis of this management plan, treatment can be instituted. The notes and resources that follow give more specific evidence-based guidance, on a range of management issues.

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Notes Screening

Relaxation and stress reduction

Screening all patients by asking two questions about mood (feeling down, depressed or hopeless) and anhedonia (little interest or pleasure in doing things) is useful as a routine procedure for at-risk patients and, if done, should be followed up by a diagnostic assessment and management as appropriate (ICSI, 2008).

Relaxation and stress reduction techniques include progressive muscle relaxation, breathing exercises and mental imagery. These are helpful in reducing tension, worry and anxiety (Jorm et al, 2001).

Watchful waiting

• establish a proper sleep environment

Watchful waiting acknowledges that some depressions will get better without specific intervention. In mild depression, a wait and see approach in regard to medication is reasonable – though information and behavioural interventions should be given, and a further assessment arranged within two weeks (NICE, 2004).

• go to bed only to sleep, not to study or watch television

Information and guided self-help

• have a light snack or warm milk before going to bed

Giving information about depression, the particular type of depression, what causes it and what can help, will assist a person gain a sense of coping and competency, and reduce the distress and helplessness. Furthermore, it aids the therapeutic alliance (NICE, 2004; ICSI, 2008; Ellis & Smith, 2002). In addition, resources are available that teach people the principles of CBT, problem solving and writing a journal, which all help (see resource list on page 14).

Sleep hygiene Good sleep habits include the following:

• take regular physical exercise in the late afternoon or early evening • allow a wind-down time before bedtime • avoid alcohol, caffeine or nicotine • go to bed only when you are sleepy

• if you do not fall asleep within 15 minutes get up and go to another room and stay up until you are sleepy • get up regularly at the same time each morning (Treatment Protocol Project, 1997).

Behavioural activation Behavioural activation refers to the ‘B’ component of CBT. It includes: • monitoring of daily activities 11

• assessment of pleasure and mastery associated with engaging in various activities • scheduling of activities that engender pleasure and/or a sense of mastery • cognitive rehearsal of scheduled activities to identify obstacles • interventions to ameliorate deficits in social skills (e.g. communication skills, assertiveness). Behavioural activation is effective in the treatment of depression (Jacobsen et al, 1996).

Exercise and lifestyle Physical exercise, three times per week of at least 45 minutes, is helpful in promoting wellbeing and lifting mood. As in any behaviour (see behavioural activation) anticipating barriers and introducing a feasible plan is important (NICE, 2004; ICSI, 2008).

Exposure therapy Exposure is part of behavioural activation. It is important that people face their fears to reverse the avoidance and withdrawal behaviour that is common in depression and anxiety. Exposure can be accompanied by relaxation to reduce anxiety and arousal, and cognitive rehearsal to identify possible barriers or difficulties. Exposure should be done determinedly, but with preparation (Andrews et al, 1994).

Therapeutic counselling Problem-solving counselling is a useful intervention for many depressions presenting in primary care. It helps the patient resolve the problem, but also strengthens their sense of competency 12

and self-efficacy (NICE, 2004; ICSI, 2008). Grief counselling is used when there is an acute loss (e.g. of relationship or job). It involves talking over the situation to try and make sense of it, showing empathic support and allowing emotional expression (Worden, 2001).

Psychotherapy Psychotherapy can be used alone (without medication) for mild or moderate depression, depending on patient preference. Treatment should be given for 12 weeks in the first instance. Partial response should be expected within four to six weeks and full remission within 10 to 12 weeks (AHCPR, 1993). Antidepressant medication is required for severe depression or when recovery with psychotherapy is incomplete (i.e. when depressive symptoms persist). Cognitive therapy focuses particularly on the cognitions that lie behind the emotional state and is particularly appropriate for people expressing depressed cognitions – pointlessness, hopelessness, unworthiness and pessimism. Combined with behavioural activation it is referred to as cognitive behaviour therapy (CBT). Interpersonal therapy is a short-term therapy focusing on the interpersonal issues associated with grief and loss, role transition (e.g. retirement) and role disputes. CBT and brief interpersonal or dynamic psychotherapies are effective in the treatment of depression (NICE, 2004; ICSI, 2008).

Antidepressants

Collaborative care

Antidepressants are indicated for adults with moderate to severe depression, when there is evidence of melancholic depression (with anhedonia, psychomotor retardation), when counselling or psychotherapy has not been totally effective, or when the past history of the person suggests their depression is usually responsive to medication.

The term collaborative care is used to describe a systematic multidisciplinary approach to patient care. Using a care manager, who is frequently a nurse or psychologist, it facilitates communication between the primary and secondary health care systems and the patient. While not adding any active therapeutic ingredient, it facilitates optimal care through better communication and collaborations, and more active monitoring and follow-up. Early research of collaborative care models suggest that they do produce short- and long-term benefits in patient outcomes (Gilbody et al. 2006).

Patients should be reviewed weekly until significant response is achieved to ensure engagement in treatment and to address side-effects (ICSI, 2008). Once begun, medication dose should be increased, changed or augmented if there is no partial response by four to six weeks or full remission by 10 to 12 weeks. Specialist psychiatric advice is appropriate when changing or combining drugs. Antidepressants should be continued for at least four to nine months after depressive symptoms have remitted. Patients who have two or more episodes in a five-year period may be considered for continuing maintenance antidepressant therapy (AHCPR, 1993). Some form of psychological therapy, in addition to medication, will improve recovery and reduce relapse. For adolescents with depression, antidepressants can be used if indicated but, because of safety concerns, are not considered first-line treatment (beyondblue 2010).

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Resources

Resources to give to patients beyondblue provides resources on depression and anxiety, free of charge, to the Australian community. We have an extensive catalogue of resources for the people who experience depression and anxiety, their partners, family and friends, and for health professionals who work in mental health.

Depression and anxiety: An information booklet This 60-page information booklet aims to provide clear and comprehensive information about depression and anxiety, including what the conditions are, common symptoms and how to recognise them, how to get help for yourself or for someone you know, and how to stay well.

A guide to what works for depression booklet This is a comprehensive review of all known treatments for depression – including medical, psychological, complementary and lifestyle interventions.

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Getting help – How much does it cost? fact sheet The cost of getting treatment for depression, anxiety or a related disorder from a health professional varies. This fact sheet looks at the government rebates available to help pay part of the cost of psychological treatments. Visit www.beyondblue.org.au/resources or call the beyondblue support service on 1300 22 4636 to download or order these and other resources.

Beating the blues: A self help approach to overcoming depression By Susan Tanner and Jillian Ball Based on cognitive behaviour therapy (CBT), this book takes readers through a step-by-step therapy program for overcoming both low moods and more serious depression.

Blue Pages www.bluepages.anu.edu.au/home/ Provides information on treatments for depression, screening tests for depression and anxiety, a depression search engine, and links to other helpful resources.

Resources for General Practitioners Blashki G, et al (2007). General Practice Psychiatry. Sydney: McGraw Hill. Written specifically for General Practitioners, this is a comprehensive guide to treatments and diagnosis of mental illness. Davies, J (2003). A Manual of Mental Health Care in General Practice. Canberra: Commonwealth Department of Health and Ageing. Written specifically for General Practitioners, this is a comprehensive guide to treatments and diagnosis of mental illness. National Institute for Clinical Excellence (NICE) (2004). Clinical Guideline 23. Depression: management of depression in primary and secondary care, London: National Institute for Clinical Excellence. This is a detailed summary of the evidence regarding effective treatments for depression. It is available from the web in full form or as a Quick Reference Guide.

• Clinical practice guidelines: Depression in adolescents and young adults • Clinical practice guidelines for depression and related disorders – anxiety, bipolar disorder and puerperal psychosis – in the perinatal period. A guideline for primary care health professionals beyondblue has also produced several companion documents to support the Clinical Practice Guidelines. To download the Clinical Practice Guidelines and companion documents visit www.beyondblue.org.au/resources or call the beyondblue support service on 1300 22 4636.

Clinical Practice Guidelines beyondblue has led the development of NHMRC-approved Clinical Practice Guidelines for the treatment of depression in pregnant women, mothers and young people. The beyondblue Clinical Practice Guidelines draw on the latest high quality research evidence to provide Recommendations and Good Practice Points that can be used to identify, treat and manage depression, anxiety and related disorders.

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Appendix 1

Assessing the severity of depression2 Symptom cluster

Mild

Moderate

Severe

Mood

• • • • •

• Reduced pleasure in things • Reduced interest in things • Reduced reactivity of mood

• No pleasure in things • No interest in things • No reactivity of mood

Depressive thought

• Loss of confidence

• Feeling worthless or a failure • Pessimism about things generally

• Hopeless, see no future • Self-reproach, guilt, shame • Consider illness a punishment • Paranoid or nihilistic delusions

Cognition

• Minor forgetfulness or lack of concentration

• Indecisiveness • Forgetfulness

• Unable to make decisions • Slowed thinking, seems cognitively impaired (pseudodementia)

Lowered mood Reduced joy Crying Anxiety Irritability

 Adapted with permission from Clarke, Blashki & Hickie, 2007, page 114.

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Depressive thought

• Loss of confidence

• Feeling worthless or a failure • Pessimism about things generally

• Hopeless, see no future • Self-reproach, guilt, shame • Consider illness a punishment • Paranoid or nihilistic delusions

Cognition

• Minor forgetfulness or lack of concentration

• Indecisiveness • Forgetfulness

• Unable to make decisions • Slowed thinking, seems cognitively impaired (pseudodementia)

Symptom cluster

Mild

Moderate

Severe

Somatic

• Low drive • Loss of interest in food • Lowered libido • Mild initial insomnia; wake one to two times a night

• Low energy, drive • Eat with encouragement; mild weight loss • Loss of libido • Initial insomnia, wake several times a night

• No energy, drive • Unable to eat; severe weight loss • No libido • Psychomotor retardation or agitation • Sleep only a few hours

Social

• Mild social withdrawal

• Apathy and social withdrawal • Work impairment

• Apathy and social withdrawal • Marked work impairment • Poor self-care

Suicidality

• Life not enjoyable • Helplessness

• Hopelessness • Life not worth living • Thoughts of death or suicide

• Evidence of intent to suicide (plans, attempts)

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Appendix 2

A guide to undertaking a suicide risk assessment Suicide risk assessment can be considered in three hierarchical steps. 1. The risk of suicide is related in the first place to the severity of depression (see Appendix 1) and, in particular, to the degree of: • anhedonia – the loss of ability to experience pleasure • persistent helplessness and resulting hopelessness • shame and/or guilt. 2. If any of these are evident, other demographic and situational factors become important: • male • divorced • living alone • concomitant physical illness • heavy alcohol use.

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3. If there is concern, questions about suicide should be asked in a graded order, such as illustrated here: a. Have you felt at times like giving up, that life is not worth living? How often have you felt that way? b. Have you contemplated death or thought about killing yourself? How often have you had those thoughts? c. Have you thought about how you might kill yourself if you were to do that? (Think about access to means in the answer to this question) d. What has stopped you? e. Do you feel you are likely to suicide now? f. Have you ever actually tried to suicide (either recently or in the past)?

Appendix 3

ICD-101 description of mania (manic episode)

ICD-101 description of a depressive episode

Mood is elevated out of keeping with the individual’s circumstances and may vary from carefree joviality to almost uncontrollable excitement. Elation is accompanied by increased energy, resulting in overactivity, pressure of speech and a decreased need for sleep. Normal social inhibitions are lost, attention cannot be sustained and there is often marked distractibility. Self-esteem is inflated and grandiose or over-optimistic ideas are freely expressed. Perceptual disorders may occur, such as the appreciation of colours as especially vivid (and usually beautiful), a preoccupation with fine details of surfaces or textures and subjective hyperacusis. The individual may embark on extravagant and impractical schemes, spend money recklessly or become aggressive, amorous or facetious in inappropriate circumstances. In some manic episodes, the mood is irritable and suspicious rather than elated.

In typical depressive episodes, the individual suffers from: 1. depressed mood 2. loss of interest and enjoyment 3. reduced energy leading to increased fatiguability and diminished activity. Other common symptoms are: 4. reduced concentration and attention 5. reduced self-esteem and selfconfidence 6. ideas of guilt and unworthiness 7. bleak and pessimistic views of the future 8. ideas or acts of self-harm or suicide 9. disturbed sleep 10. diminished appetite. In ICD-101, a mild depressive episode requires the presence of at least four symptoms, including at least one of one to three; a moderate depressive episode requires six or seven symptoms; a severe depressive episode is defined by the presence of at least eight symptoms.

 The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines. Geneva, World Health Organization, 1992.

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Appendix 4

Symptoms of the melancholic sub-type (ICD-101 somatic syndrome) • Marked loss of interest or pleasure • Loss of emotional reactivity • Waking early in the morning, two hours before usual time • The feeling of depression is worse in the morning • Evident psychomotor retardation of agitation • Marked loss of appetite • Significant weight loss (5 per cent or more in the past month) • Loss of libido A formal diagnosis of somatic syndrome in ICD-101 requires four or more of the above.

 The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines. Geneva, World Health Organization, 1992.

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References AHCPR (1993) Publication No. 93-0551. Depression in primary care: Vol 2. Treatment of Major Depression. Rockville MD.

Clarke DM, Blashki G, Hickie IB. (2007). Depression. In: G Blashki, F Judd, L Piterman (eds). General Practice Psychiatry. Sydney: McGraw Hill, pages 108-126.

American Psychiatric Association Work Group on Major Depressive Disorder (2000). Practice guideline for the treatment of patients with major depressive disorder (2nd edition). Washington, DC: American Psychiatric Association.

Ellis PM, Smith DAR. (2002). Treating depression: the beyondblue guideline for treating depression in primary care. Medical Journal of Australia, 176, S77-S83.

Andrews G, Crino R, Hunt C, Lampe L, Page A. (1994). The treatment of anxiety disorders: Clinician’s guide and patient manuals. Cambridge: Cambridge University Press. (See ‘graded exposure’ in index.) beyondblue (2010) Clinical practice guidelines: Depression in adolescents and young adults. Melbourne: beyondblue Blashki G, Judd F, Piterman L. (2007). General Practice Psychiatry. Sydney: McGraw Hill. Clarke DM, Cook K, Smith GC, Piterman L. (2008). What do general practitioners think depression is? A taxonomy of distress and depression in general practice. Medical Journal of Australia, 188, S110-113.

Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. (2006). Collaborative care for depression: a cumulative meta‑analysis and review of longerterm outcomes. Archives of Internal Medicine, 166, 2314-2321. Institute for Clinical Systems Improvement (ICSI) (2008). Health Care Guideline: Major Depression in adults in primary care. Institute for Clinical Systems Improvement. Jacobsen NS, Dobson KS, Truax PA, Addis ME, Koerner K, Gollan JK, Gortner E, Prince SE. (1996). A component analysis of cognitive-behavioural treatment for depression. Journal of Consulting and Clinical Psychology, 64, 295-304. Jorm A, Christensen H, Griffiths K, Korten A, Ridgers B. (2001). Help for depression: what works (& what doesn’t). Canberra: Centre for Mental Health Research, Australian National University.

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Kennedy SH, Lam RW, Nutt DJ. Thase ME. (2007). Treating depression effectively: applying clinical guidelines (2nd edition). London: Informa Healthcare.

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Normal sadness

Moderate depression

• availability of resources.

• preferences for treatment

Chronic depression

Collaborative care

Psychiatrist advice

Medication

Cognitive, interpersonal or dynamic psychotherapy

Grief counselling / Problem solving therapy

Information, mobilising support, self-help, behavioural activation

• severity

• the way we understand the depression (type, context)

Treatment is determined by:

Mild depression

Recurrent depressive episodes

or

Less common but important (not to be missed)

(anhedonia, absence of joy, no interest or drive, slowed up)

Unipolar / bipolar depression

Chronic depression Chronic sadness or misery

‘Disorder’ Melancholic depression

Severe depression

Mixed anxiety and depression

Normal  ➤ Complicated (feelings of loss, pangs of grief, pining)

Common (probability diagnoses)

Anxious depression

Grief/Loss

➤

can’t cope, despairing demoralised, given up

helplessness

stressed and worried ➤

Hopelessness depression

Depressive reaction

• duration.

• context (stressor, no stressor, bereavement)

Anxiety

‘Problems’

• severity

• symptom type

Depression is categorised by:

Distress / Depression symptoms

Hope. Recovery. Resilience. Find out more at www.beyondblue.org.au

Where to find more information beyondblue www.beyondblue.org.au Learn more about depression and anxiety, or talk it through with our support service.

1300 22 4636 Email or chat to us online at www.beyondblue.org.au/getsupport

Lifeline www.lifeline.org.au 13 11 14 Access to crisis support, suicide prevention and mental health support services.

mindhealthconnect www.mindhealthconnect.org.au Access to trusted, relevant mental health care services, online programs and resources.

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